Managed Care

Disease Management

Effective case management, at an individual beneficiary level, leverages off the on‐going managed care initiatives, and is elevated to the level of integrated care by AFA’s disease management programmes. The success of this area of AFA’s business is facilitated by the Managed Care Programme.

This programme uses a customer and cost‐effective centralized treatment authorization model which is responsible for the clinical and financial management of chronic diseases, including HIV/AIDS and related conditions. The ability to measure the outcome of product application provides AFA with the information to continually enhance and expand its products profile.

  • Disease management

  • Effective case management

  • Clinical and financial management of chronic diseases, including HIV/AIDS and related conditions.

Technology

In recognition of the fact that information management remains one of the key enablers for innovation and relevant policy formulation and decision making, AFA invested in an integrated and flexible information management system capable of handling multiple health insurance funds, multiple sub‐recipients and multiple options within the funds, depending on the needs of the client.

The IT System, which was implemented in August 2009 allows for end‐to‐end integration of all vital business processes of fund management and administration to support seamless supplier registration, case management, data capture, adjudication and service provider payment with optional electronic supplier notification of payments.

Client specific transaction adjudication / assessing rules are built into the IT System for automated djudication and payment. The automated adjudication includes, among others, the following;

  • Validation of clients’ beneficiaries e.g. medical aid sa• echeme beneficiaries)

  • Automatic allocation of benefitial limits and maintennce thereof per beneficiary

  • Automatic benefits limit checking per beneficiary.

  • Automatic duplicate claims checking, duplicate claims are auto‐rejected with reason attached

  • Automatic exclusion from benefit checks ‐items or services excluded from benefit per beneficiary will not be paid.

  • Direct payment to service providers’ bank accounts

  • Direct payment to individual member accounts; and Data management for Monitoring and Evaluation with auto‐generated routine and/or ad‐hoc reports.

Another major feature of the IT System is that it utilizes a Document Management System where all correspondence and documentation can be scanned for archiving and the images linked to the corresponding transactions. Authorized users within business functions can retrieve documents whenever the need arises.

Furthermore, the IT Systems used by AFA facilitate e‐commerce communication and transactions as well as easier reporting, both ad‐hoc and standardized report generation to facilitate monitoring and evaluation of the various aspects of fund management/administration, as well as AFA’s reporting to its clients. In addition to the administration system outlined above, AFA uses a Disease Management System for HIV/AIDS Management which allows for maintenance of comprehensive treatment profiles for all enrolled patients, maintenance of clinical outcomes as tracking of interacting between the Chronic Clinical Staff and the Clients as well as reporting on individual and program outcomes.

Connectivity

EDI

AFA has been able to launch a range of electronic services for both our strategic partners and our clients. Electronic Data Interchange (EDI) was rolled out in 2012 to enable Service providers and hospital networks to timeously submit claims in a paperless environment.

ERA

Electronic Remittance Advice (ERA) was developed as add‐on product to our electronic services bouquet and provides our strategic partners (service providers) remittance statements in an editable format. This aims to assist with reconciliations for payments.

Webaccess

The administered schemes with an excess of 87,000 principal members, who are able to login to their account to view a range of services and send updates, view statements, benefit availability and membership verification. The system is integrated seamlessly enabling clients to interface with the
scheme 24/7.

For more information visit
www.pulamed.co.bw and www.bpomas.co.bw